Therapeutic Services Referral Form
Thank you for choosing Gateway Mountain Center for your mental health needs! Our staff are eager to help you discover and fully realize your best self. To help us meet your unique needs, please fill out this form as completely as possible.
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Email *
Gateway has an AWESOME array of youth programming & services. Let's start by exploring some possibilities from our most popular and sought after options. (Pssst it's okay if you are unsure. We'll help you out!) *
Required
Client Information
Client Legal Name *
Date of Birth *
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Age *
*
Required
Family Information
Caregiver/s Name
Caregiver Phone Number
Caregiver Email
Full Address *
Ability to Pay
Gateway seeks family support to pay for programs whenever possible. Gateway is also often able to serve families who can not pay for services. Please share what your current ability is to pay for the services provided.
Ability to Pay *
Referring Party Contact Information
Referring Organization
Referring Party Name
Referring Party Phone Number
Referring Party Email
Relationship to Client *
Are you available to talk about this referral?
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Reason For Referral *
Desired Outcome from treatment *
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